Firazyr (icatibant) — Medica

Initial criteria

• Patient has HAE type I or type II as confirmed by both of the following laboratory findings: low levels of functional C1-INH protein (< 50% of normal) at baseline AND lower than normal serum C4 levels at baseline [documentation required]
• A diagnosis of HAE with normal C1-INH (also known as HAE type III) does NOT satisfy this requirement
• Medication is prescribed by or in consultation with an allergist/immunologist or a physician who specializes in the treatment of HAE or related disorders

Reauthorization criteria

• Patient has a diagnosis of HAE type I or type II [documentation required]
• According to the prescriber, the patient has had a favorable clinical response with icatibant treatment (e.g., decrease in duration of HAE attacks, quick onset of symptom relief, complete resolution of symptoms, or decrease in attack frequency or severity)
• Medication is prescribed by or in consultation with an allergist/immunologist or a physician who specializes in the treatment of HAE or related disorders

Approval duration

1 year